Motor Vehicle Accident Claim Form
|
|
- Thomasine Gwen Miles
- 8 years ago
- Views:
Transcription
1 Motor Vehicle Accident Claim Form THE COMPLETION OF THIS FORM AND ITS RECEIPT BY US IS NOT AN INDICATION THAT WE ACCEPT ANY LIABILITY. WE HAVE QUALITY REPAIRERS TO HELP YOU IN THE EVENT OF A CLAIM. PLEASE PRINT IN BLOCK LETTERS and answer all Questions where applicable (provide full and complete answers). If a particular question does not apply, please write Nil in the space provided. If the space provided below is insufficient to advise all the details, please attach a separate sheet. THIS FORM SHOULD BE COMPLETED AND RETURNED WITHIN 7 DAYS OF RECEIPT BY THE INSURED. NO REPAIRS SHOULD BE CARRIED OUT WITHOUT THE APPROVAL OF NRMA INSURANCE. A COPY OF ANY QUOTE FOR REPAIRS SHOULD BE INCLUDED WITH THIS FORM. INSURED S DETAILS Name of Insured Mr Mrs Miss Ms Claim No. Policy No. Expiry Date Excess $ Telephone No. Mobile No. Contact Name Name of Registered Owner Phone No. (private) (business) (1) Are you registered for GST? No Yes (2) What is your Australian Business Number (ABN)? (3) Are you entitled to any Input Tax Credit (ITC) if you repair or replace the property damaged? No Yes If yes, what is your percentage entitlement? % (4) What was your Entitlement to an Input Tax Credit (EITC%) on your premium payment for this policy? % VEHICLE DETAILS (5) Year of Manufacture Vehicle Make and Model Body type e.g. Sedan, Utility No. of Cylinders Chassis/VIN No. Engine No. Registration No. (6) Please list all accessories or other equipment which has not been fitted by the vehicle manufacturer (7) Is Vehicle subject to Finance? (Mortgage/Bill of Sale/Hire Purchase/Lease) No Yes Name Branch Contract No. (if known) DRIVER S DETAILS (8) Driver or person last in charge of your vehicle. Name Date of Birth (9) Driver s Licence No. Classes Expiry Date of Driver s Licence Years held Type of Licence Full Probationary Learners (10) Has the driver had any accidents, traffic convictions and/or penalties in last 5 years? No Yes If yes, give full particulars. (11) Has the driver s licence ever been suspended or cancelled? No Yes (a) When (b) State reason (12) If the driver is not the Insured, please state: (a) Was the vehicle being driven with the Insured s knowledge or consent? No Yes (b) Was the driver a paid employee of the Insured? No Yes (c) Does the driver have an insurance policy on their own vehicle? No Yes If yes, Name of company Policy No. (d) Has the driver ever been refused vehicle insurance or continuance thereof by an insurer? No Yes If yes, Name of company Insurance Australia Limited ABN AFS Licence No trading as SGIO GPO Box 3978 Sydney NSW 2001 Telephone Facsimile RBIClaims@iag.com.au Page 1 of 5
2 DRIVER S DETAILS (Continued) (13) Was the driver taken to hospital? No Yes (14) Had the driver consumed within 24 hours preceding the accident any drugs or alcohol? No Yes If yes, please state the nature and quantity of drugs and/or alcohol consumed: (15) Were you requested to take a blood, breath or urine test? No Yes If yes, give details of Type of Test: Blood Test Urine Test Alco-Test Full Breathalyser What was the reading? NOTE: DOCUMENTARY PROOF OF THE RESULT OF A BLOOD OR BREATHALYSER TEST MUST BE PROVIDED TO US POLICE, TRAFFIC AND OTHER ACTION AGAINST YOU OR YOUR DRIVER (16) Did police attend accident and take particulars? No Yes (17) Has driver reported accident to the police? No Yes Where Report Number Date reported (18) Was any charge laid or intimated against driver? No Yes Nature of charges VEHICLE INFORMATION (19) Was the vehicle being used for business at the time of the accident. No Yes If yes, please state the nature of business: If goods carrying vehicle please state: (a) Nature of load (b) Weight of load (20) Describe damage to insured vehicle in this accident: Place X on diagram to show areas of damage. (21) Was there pre-existing damage? No Yes (22) Was vehicle towed? No Yes By Whom? When Present location of vehicle (23) Choice of Quality Repairer Repair Quote $ (24) When will vehicle be left at repairer s workshop to be inspected? NOTE: Please phone us to report the accident and to arrange inspection for repairs to proceed without delay. Where an accident has occurred beyond Metropolitan Area, an itemised quotation should be sought from a local repairer and sent with this form (except TPPD). Page 2 of 5
3 DETAILS OF OTHER VEHICLE OR PROPERTY Please supply full names of other driver, also their private and business address. This will assist recovery of your repair costs. (25) Owner s Surname Other Names (26) Phone No. (27) Driver s Surname Other Names Approx. Age (28) Phone No. (29) Vehicle Make Body type Reg. No. (30) Describe damage to vehicle and/or property Approx. Cost $ (31) Is this vehicle insured? No Yes If yes, state Name of company (32) Is the other driver known to you? No Yes If yes, how? DETAILS OF ALL WITNESSES *State if the witness was: (a) an independent witness; (b) in the insured vehicle; or (c) in the third party vehicle. (See below) (33) Were there any witnesses to this accident? No Yes If yes, provide details: Name Phone No. Age * (a) (b) (c) Name Phone No. Age * (a) (b) (c) DETAILS OF ACCIDENT (34) Have you previously reported this accident to us? No Yes How? (35) Date of accident Time am/pm (36) Where did accident occur? Street Town/Suburb (37) (a) Speed of your vehicle At the moment of impact Before emergency arose (b) Speed of other vehicle At the moment of impact Before emergency arose (38) (a) What lamps were alight? (i) On your vehicle? (ii) On the other vehicle? (b) Were indicators operating? (i) On your vehicle? (ii) On the other vehicle? (39) What was the road surface like? Wet Dry Loose Traffic controls None Traffic Lights Give Way Sign Stop Sign Roundabout Other (40) How many vehicles were involved (including your own) (41) State clearly and fully how the accident occurred (If insufficient space, please attach a separate written statement.) (42) Who, in your opinion was to blame for the accident? Why? (43) Has any claim been made against you? No Yes Page 3 of 5
4 DIAGRAM OF ACCIDENT (44) Name the streets (45) Indicate directions with arrows, so: (46) Indicate distances so: 12ft or 4m (47) Show accurately the position of the pedestrian or vehicles involved in the accident and witnesses. (48) Show your vehicle other vehicle (49) Show point of impact so: X (50) Show existence of any road signs at intersections N Please draw a PLAN OF THE ROADWAY where the accident happened. W E S BEFORE SIGNING PLEASE READ THIS IMPORTANT INFORMATION NO CLAIM BONUS - Your No Claim Bonus may be affected depending on the circumstances of the Loss and the cover selected. EXCESS - You must pay all applicable excesses before we are liable for any payment under this policy. Page 4 of 5
5 DECLARATION I hereby authorise the Insurer to obtain any report or statement that I have made to the police. No information likely to affect the acceptance of this claim has been withheld. I understand that this claim may be refused if any information is false, or inaccurate or concealed. I consent to the Insurer, in assessing or otherwise dealing with this claim, disclosing my personal information to or collecting my personal information from related entities, other insurers, insurance reference bureaux, investigators, or other parties providing services to the Insurer. I/we agree that, by submitting this form, the personal information I/we provide in this form or otherwise may be collected, held, used and disclosed in the manner set out in our Privacy Policy. Where I/we have provided information about another individual, I/we confirm that I/we have provided notice to and obtained the consent of that individual in the manner required in the Privacy Policy. The foregoing information is, to the best of my knowledge and belief, true in every respect. I consent to the Insurer, in assessing or otherwise dealing with this claim, disclosing my personal information to or collecting my personal information from related entities, other insurers, insurance reference bureaux, investigators, or other parties providing services to the Insurer. I hereby submit the foregoing information in support of my formal claim for indemnity under my policy and I hereby authorise the Insurer to obtain any report or statement that I have made to the police. Signature of INSURED Date Note: A copy of the Privacy Policy is on our website or can be sent to you by contacting us on Signature of DRIVER Age of DRIVER or person last in charge of vehicle Date PLEASE ENSURE THAT ALL QUESTIONS HAVE BEEN ANSWERED G /13 Page 5 of 5
Commercial Motor and Motor Fleet Claim Form
Commercial Motor and Motor Fleet Claim Form The completion of this form and its receipt by us is not an indication that we accept any liability. Please print in block letters and answer all Questions where
More informationMotor Vehicle. Claim Form PLEASE RETURN COMPLETED FORM TO YOUR JLT OFFICE:
Motor Vehicle Claim Form PLEASE RETURN COMPLETED FORM TO YOUR JLT OFFICE: GPO Box 1693 ADELAIDE SA 5001 Tel +61 (0)8 8235 6446 Fax +61 (0)8 8235 6448 PO Box 925 ALBURY NSW 2640 Tel +61 (0)2 6057 3333 Fax
More informationMOTORCYCLE CLAIM FORM ACCIDENT DAMAGE (The issue of this form is not an admission of liability)
MOTORCYCLE CLAIM FORM ACCIDENT DAMAGE (The issue of this form is not an admission of liability) This form should be completed and forwarded to - ECHELON CLAIMS SERVICES GPO Box 1693 Adelaide SA 5001 Facsimile:
More informationGive details of your vehicle involved in the accident - Year Make (e.g. Holden) Model (e.g. Commodore) Registration No.
Echelon Claims Services is a division of Echelon Australia Pty Ltd ABN 96 085 720 056 Address: PO Box 7170, Hutt Street, Adelaide South Australia 5000 Ph (08) 8235 6455 Free call 1800 640 009 Facsimile
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to
More information1. Your Details 2. Insured Vehicle Description
MOTOR VEHICLE CLAIM The issue or acceptance of this form is not to be construed as an admission of liability on the part of the company. Shaded areas for office use only. Please print clearly. Claim Number
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM The Issue of this Form is not an Admission of Liability by Insurers We understand the difficulties arising from your accident. Please complete and return this claim form as soon
More informationTHE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM.
CLAIM FORM Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY CLAIM
More informationMotor Vehicle. Claim Report
Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the
More informationHow To Fill Out A Claim Form For A Car Accident In The Uk
Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationMOTOR VEHICLE ACCIDENT CLAIM REPORT
MOTOR VEHICLE ACCIDENT CLAIM REPORT CGU Insurance Limited ABN 27 004 478 371 Please retain this page for your information ABOUT YOUR CLAIM Please obtain one quotation for the repair of your vehicle from
More informationmotor vehicle motor vehicle insurance for privately owned non-commercial vehicles accident claim report
motor vehicle insurance for privately owned non-commercial vehicles motor vehicle accident claim report Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company CGU Insurance Limited ABN 27 004
More informationClaim form Motor Vehicle
Claim form Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY Claim
More informationMotor Vehicle Claim Form
SSAA Insurance Brokers Pty Ltd Phone (08) 8332 0281 The Precinct Freecall 1800 808 608 Suite 14, 539 Greenhill Road Facsimile (08) 8332 0303 539 Greenhill Road Email insurance@ssaains.com.au Hazelwood
More informationDAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES
DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM PO Box 2717 Taren Point NSW 2229 Telephone: 1300 188 299 Facsimile: 1300 662 215 Email: claims@dawes.com.au www.dawes.com.au Before completing this claim
More informationMOTOR VEHICLE ACCIDENT Claim Report
MOTOR VEHICLE ACCIDENT Claim Report HBA General Insurance and Mutual Community General Insurance Insurer: Mutual Community General Insurance Pty Ltd Abn 59 007 895 543 Please retain this page for your
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationMotor Vehicle Claim Form
1st Floor, 50 Hindmarsh Square Adelaide SA 5000 PO Box 6095 Halifax St Adelaide 5000 Phone 08 8413 6300 Facsimile 08 82119838 enquiries@brecknock.com.au brecknock.com.au Motor Vehicle Claim Form We re
More informationCTP At-fault Driver Policy Claim form
CTP At-fault Driver Policy Claim form Complete this form if the at-fault driver was driving a vehicle with NRMA CTP Insurance and sustained an injury listed in question 5 or died as a result of the motor
More informationMotor Vehicle. Accident Claim Form COMPLAINTS PROCEDURE. Financial Ombudsman Service. Privacy Statement. General Insurance Code of Practice
COMPLAINTS PROCEDURE Enthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no cost and aims to resolve claims complaints
More informationMOTOR VEHICLE CLAIM FORM (Accident or Theft)
Cowden Group MOTOR VEHICLE CLAIM FORM (Accident or Theft) The supply or acceptance of this form is not an admission of liability on the part of your Insurer 1. Your Details Policy No Expiry of Insured
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationMotor Vehicle Insurance Claim
Motor Vehicle Insurance Claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring
More informationDAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES
DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM P.O. Box 2717 Taren Point NSW 2229 Phone: 1300 188 299 Fax: 1300 662 215 claims@dawes.com.au To ensure prompt attention to your claim, please complete this form
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM How to obtain a quick response to your claim: 1. Make sure that you fully answer all questions 2. Attach a copy of the Driver s Licence for the driver of the vehicle at the time
More informationMotor Vehicle Insurance Claim. Insured
Suite 5 & 6 156 Oxford St, Leederville WA 6007 PO Box 495, Leederville WA 6903 Freecall: 1800 776 747 Facsimile: 1800 194 525 Email: info@mynfib.com.au ABN 23 108 296 064 National Franchise Insurance Brokers
More informationMotor Vehicle Insurance Claim. Insured
INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Motor Vehicle
More informationMotor Vehicle Accident Claim Form
Motor Vehicle Accident Claim Form Please note, no repairs are to commence without the consent of your insurer. -+ A trading name of Austbrokers RIS Pty Ltd ABN 25 094 825 859 AFS Licence No. 239 291 Level
More informationCOMMERCIAL MOTOR CLAIM FORM
COMMERCIAL MOTOR CLAIM FORM Please complete in full all sections of this claims form and return it to Insuret as soon as possible after the accident. Unless specifically arranged beforehand, no repairs
More informationCommunity Underwriting Motor Claim Form
Community Underwriting Motor Claim Form About the Insurer Calliden Insurance Limited (Calliden) (ABN 47 004 125 268), is a public company incorporated in Australia. It is authorised under the Australian
More informationSteadfast Taswide Pty Ltd ABN 24 092 613 664 AFS Licence No. 238451. enquiries@steadfasttaswide.com.au www.steadffasttaswide.com.
WHK Centre, Level 4 142 Elizabeth Street, Hobart TAS 7000 Ph (03) 6231 3360 Fax (03) 6231 6053 Steadfast Taswide Pty Ltd ABN 24 092 613 664 AFS Licence. 238451 enquiries@steadfasttaswide.com.au www.steadffasttaswide.com.au
More informationMotor vehicle insurance claim form
Motor vehicle insurance claim form Suva: 231 Waimanu Rd Phone: 331 1055 Fax: 330 3475 Nadi: Main Street Phone: 670 1451 Fax: 6701221 Important Notes To assist Dominion Insurance Limited ( us/our/we ) process
More informationMotor Vehicle Claim Form
phone: +64 9 377 4314 fax: +64 9 373 4882 email: claims@icib.co.nz web: www.icib.co.nz Level 7, 26 Hobson Street Auckland, PO Box 3174 Auckland 1140, New Zealand Motor Vehicle Claim Form Policy Details
More informationCLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle
Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim
More informationMOTORCYCLE INSURANCE CLAIM FORM
MOTORCYCLE INSURANCE CLAIM FORM PO BOX 6156, NORTH SYDNEY, NSW, 2059 PHONE: 1300 781 448 FAX: 02 8920 1275 E-MAIL: CLAIMS@MI-BIKE.COM.AU Please ensure that all questions are answered in full in as much
More informationVEHICLE ACCIDENT CLAIM FORM
Please help us to help you by: completing all relevant questions in full as this can avoid the need for further enquiry and possible delay in settling your claim signing and dating page 7 of this form
More information2. The Insured (Vehicle owner)
mobile plant liability claim form WFI Insurance Limited, ABN 24 000 036 279 The issue of this form must not be taken as an admission of liability. Form is to be completed as far as possible by the driver
More informationHEAVY MOTOR FLEET INSURANCE CLAIM FORM
HEAVY MOTOR FLEET INSURANCE CLAIM FORM Take precautions to ensure that no further damage or loss occurs to the vehicle. Where possible have the vehicle moved to a secure location if not drivable. Obtain
More informationMotor Vehicle Accident Claim form
Motor Vehicle Accident Claim form Complaints procedure Enthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no
More informationPLEASURE CRAFT / HULL CLAIM FORM
PLEASURE CRAFT / HULL CLAIM FORM INSURANCE BROKERS The Issue of this Form is not an Admission of Liability by Insurer Policy # : Claim # : Please complete and return this claim form as soon as possible,
More informationMotor Vehicle Accident
Motor Vehicle Accident Claim Form Claim Number (office use only) How to Get Quick Action on Your Claim Catholic Church Insurance Limited will act on your claim as soon as we receive this form. You can
More informationClaim Form. Motor Vehicle. Section 1 (To be completed by Owner): Occupation. Name of insured. Address. Phone No [ ] Year Model.
Section 1 (To be completed by Owner): Policy no Name of insured Occupation Expiry Date Phone No [ ] Make of Vehicle Mileage Registration No Year Model Co-Owner In whose name is the registered? For what
More informationMotor Vehicle Accident Report Form
Motor Vehicle Accident Report Form 1300 725 788 Your Car, Your Choice Know Your Rights Service & Quality Guaranteed One Call Does It All Owner s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) Full Name
More information(The issue of this form is not an admission of liability)
Echelon Claims Services is a division of Echelon Australia Pty Ltd ABN 96 085 720 056 GPO Box 1693, Adelaide, South Australia 5001 Ph (08) 8235 6455 Free call 1800 640 009 (08) 8235 6450 Trust LIIABIILIITY
More informationClaim Form. Journey Report Form. To be completed by Policyholder
This form must be accompanied by an Attending Physicians Statement, which can be obtained by telephoning any of our offices listed. By furnishing this Form the Company makes no admission of Liability or
More informationHERTZ Personal Accident & Effects Claim Form
HERTZ Personal Accident & Effects Claim Form Trust Name: ABN: (The issue of this form is not an admission of liability) JLT (Hertz PA/PE Cover) Discretionary Trust Arrangement This form should be completed
More informationProperty Claim Report
Property Claim Report This form is to be used for reporting a claim for lost, stolen or damaged property, including: Accidental damage Illegal use of credit card Accidental loss Impact Burglary Lightning
More informationHome Insurance. Claim Report
Home Insurance Claim Report CGU Insurance Limited ABN 27 004 478 371 AFSL 238291 Please retain this page for your information About your claim Most policies allow for replacement of property with the nearest
More informationmotor vehicle insurance for privately owned non-commercial vehicles motor vehicle theft claim report Insurer CGU Insurance Limited ABN 27 004 478 371
motor vehicle insurance for privately owned non-commercial vehicles motor vehicle theft claim report Insurer CGU Insurance Limited ABN 27 004 478 371 CGU Insurance Limited ABN 27 004 478 371 Please retain
More informationImportant message for customers wishing to make a claim on their policy
Important message for customers wishing to make a claim on their policy Before we can action your claim, can you please : Fully complete the attached claim form If your vehicle is driveable, call us to
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationhome insurance home claim report
home insurance home claim report CGU Insurance Limited ABN 27 004 478 371. An IAG Company. Please retain this page for your information About your claim Most policies allow for replacement of property
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationMOTOR VEHICLE QUOTATION PROPOSAL FORM
MOTOR VEHICLE QUOTATION PROPOSAL FORM THE PROPOSER Full Insured Name Trading Name(s) ABN ACN Postal Address Contact Name State Position Post code Telephone No ( ) Facsimile No Mobile No Website E-mail
More informationFatality Claim Form. South Australia Compulsory Third Party (CTP)
South Australia Compulsory Third Party (CTP) Fatality Claim Form This form is to be completed by any person who is claiming compensation as a result of a person s death in a motor vehicle accident (please
More informationSurname Full given name Date of birth. Private phone no. Business phone no. Mobile phone no. Fax no. ( ) ( ) ( )
Golf Sporting Equipment Claim Form THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE A WRITTEN STATEMENT OF CLAIM. CASE/CLAIM NUMBER Important
More informationMOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE)
Insurance Company Limited MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder
More informationMOTOR VEHICLE ACCIDENT CLAIM FORM
MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Date Purchased: Make: Tare: Gross Vehicle Mass: Kilometers: Price Paid: Value: Year: Model: If the
More informationMotor Accident Claim Form Insured Section
Motor Accident Claim Form Insured Section Date Insured Name Insured Licence Code Licence : Date of Issue Insured Id Policy Insured Address Suburb Town Province Code Contact Person Landline Number Fax Number
More informationCompulsory Third Party Insurance Notice of Accident by Owner
Compulsory Third Party Insurance tice of Accident by Owner Please complete and mail to: CTP Claims, GPO Box 1453 Brisbane QLD 4001 Claim Reference. 1. OWNER Mr/Mrs/Ms Address (. & Street) Town/Suburb Postcode
More informationMOTOR VEHICLE ACCIDENT CLAIM FORM
MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Policy No.: VAT Reg. No.: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Make: Tare: Gross Vehicle Mass: Kilometers: Date Purchased: Price Paid:
More informationClaim Form Commercial Hull & Boat Insurance
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Claim Form Commercial Hull & Boat Insurance All questions on this claim form must be answered The Insured Insured s name Surname Given (s) Are you registered
More informationtravel insurance travel claim report
claim report travel insurance travel CGU Insurance Limited ABN 27 004 478 371 An IAG Company Please retain this page for your information IMPORTANT Please read this before completing the report. Please
More information1. Personal Statement
journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is
More information(The issue of this form is not an admission of liability)
1 JOURNEY R CLAIM FORM M (The issue of this form is not an admission of liability) Trust Name: JLT (CAAW) Discretionary Trust ABN: 98 780 034 885 JLT Discretionary Trust and Excess of Loss Insurance This
More informationHome and Contents Insurance Claim. and. corporate. Title Surname Full given name(s) Postcode Contact home phone number. Contact facsimile number ( )
BankSA Home and Contents Insurance Claim About this form Only About complete this form this form if your claim is in respect to loss of or damage to Buildings/Contents/Personal Valuables or Legal Liability.
More informationBoat Insurance Claim Form
Boat Insurance Claim Form 5. Incident Details The issue or acceptance of this form is not to be construed as an admission of liability on the part of the Company. Please provide complete details to the
More informationhome contents transit
home contents transit insurance Insurer CGU Marine Insurance A Division of CGU Insurance Limited ABN 27 004 478 371 An IAG Company claim report home contents transit CGU Marine Insurance A Division of
More informationMOTOR TRADE ROAD RISKS ACCIDENT REPORT FORM
Tradewise Insurance Services Ltd MOTOR TRADE ROAD RISKS ACCIDENT REPORT FORM Link House 292-308 Southbury Road, Enfield, Middlesex EN1 1TS Tel: 0844 620 1234 Claims Department Fax: 020 8350 2350 ENSURE
More informationAccident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.
More informationExpiry Date. If you have selected Cheque please nominate payee
TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Please answer all questions and provide all relevant documentation to avoid delays with your We are unable to process
More informationPRIVATE CAR ACCIDENT REPORT FORM
Tradewise Insurance Services Ltd PRIVATE CAR ACCIDENT REPORT FORM Link House 292-308 Southbury Road, Enfield, Middlesex EN1 1TS Tel: 0844 620 1234 Claims Department Fax: 020 8350 2350 ENSURE ALL SECTIONS
More informationPUBLIC/PERSONAL LIABILITY CLAIM FORM
ACE Insurance Limited PUBLIC/PERSONAL LIABILITY CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 PO Box 204, West Perth WA 6872 Phone: 08 6142 0000 Fax:
More informationPersonal Injury Claim Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815
More informationCouriers insurance package form
Page 1 of 5 Couriers insurance package form Important Information Duty of Disclosure Before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 (Cth) to disclose
More information1. Claimant Details. personal accident and sickness claim form
personal accident and sickness claim form Wesfarmers General Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461 Level 2, 99 Melbourne Street, South Brisbane, QLD 4101 or GPO Box 524 Brisbane,
More informationClaim Form TRAVEL INSURANCE
ACCIDENT & HEALTH INTERNATIONAL Claim Form TRAVEL INSURANCE Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS
More informationAccident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.
More informationSECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
More informationPublic Liability Insurance Claim Form
& Public Liability Insurance Claim Form Completing this Form Please answer all questions. This will help us to process your claim quickly. If you need more space to answer any of the questions or wish
More informationMotor Accident Personal Injury Claim Form
Motor Accident Personal Injury Claim Form HAVE YOU BEEN INJURED IN A MOTOR VEHICLE ACCIDENT? If you have been injured in a motor vehicle accident in New South Wales, you may be able to access benefits
More informationJLT SPORT ASSET PROTECT CLAIM FORM
JLT SPORT ASSET PROTECT CLAIM FORM PLEASE USE BLOCK LETTERS WHILE COMPLETING THIS FORM CLAIMS HOTLINE: 1800 640 009 or call direct: (08) 8235 6455 Please forward your completed claim form to: Echelon Claims
More informationSECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
More informationSECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
More information(The issue of this form is not an admission of liability) Trust Name: JLT (CSI Member Benefits) Discretionary Trust Arrangement ABN: 56 279 303 288
1 (The issue of this form is not an admission of liability) Trust Name: JLT (CSI Member Benefits) Discretionary Trust Arrangement ABN: 56 279 303 288 This form should be completed and forwarded to - Echelon
More informationClaim Form Commercial Hull & Boat Insurance
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Claim Form Commercial Hull & Boat Insurance All questions on this claim form must be answered THE INSURED Insured s Are you registered for GST? No Yes
More informationApplication for Scheduled Benefits
Application for Scheduled Benefits CLAIM FORM B To be completed by, or on behalf of, an injured driver/ passenger/motorcyclist/pillion passenger/pedestrian/cyclist Please also complete Claim Form A Notice
More informationSuburb State Postcode Residential address. Suburb State Postcode
Classic and Collector Vehicle & Motorcycle Insurance quotation & proposal form Broker or dealer details Company Name Phone Email Page 1 of 7 The applicant Full name Date of birth Email Postal address Phone
More informationQuotation Request and Proposal
Quotation Request and Proposal Richard Bowen 0800 287 287 Managing Broker MultiSure Ltd 86 Normandale Road, Lower Hutt 5010 Ph: (04) 589 3319 Fax: (04) 587 0258 Email: richard@multisure.co.nz Philip Toohill
More informationClaim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return
Savannah Insurance Agency Pty Ltd ABN 84 130 364 313 Corporate Travel Claim Form Details of the Insured Insured Name (Traveller) Policy Number Claim Number IMPORTANT 1. Please complete the Policy Details
More informationMOTOR TRADE CLAIM FORM
Insurance Company Limited MOTOR TRADE CLAIM FORM First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder s Name Company Name Policy No. (cover note
More informationMotor Accident Notification Form (MANF)
Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital
More informationGIO Claim Notification Guide Motor
GIO Claim Notification Guide Motor Date of Procedure: June 2015 Version: 1.0 ON BEHALF OF THE Table of Contents GIO Claims Notifications Motor... 3 Treasury Managed Fund (TMF)... 4 What is a claim?...
More informationTradewise Insurance Company Ltd
Tradewise Insurance Company Ltd MOTOR ACCIDENT REPORT FORM Ensure all sections of this form are completed fully. Also note that any attempt to defraud Underwriters will result in criminal prosecution.
More informationAgents financial administration Form 4
Agents financial administration Form 4 Collection agent application for authority to open a trust account Agents Financial Administration Act 2014 Debt Collectors (Field Agents and Collection Agents) Act
More informationImportant message for customers wishing to make a claim on their policy
Important message for customers wishing to make a claim on their policy Before we can action your claim, can you please: Fully complete the attached claim form and statutory declaration Return all these
More informationLandlords Residential Property Insurance Claim Report
Landlords Residential Property Insurance Claim Report CGU Insurance Limited ABN 27 004 478 371 Please retain this page for your information About your claim We will contact you as quickly as possible about
More information